Optometry Cataract Evaluation & Referral Note

Date: [encounter date]

Patient: [name, DOB, MRN per local policy]

Provider: [clinician name and credentials]

Visit Intent: [monitoring / surgical candidacy discussion / referral / post-referral follow-up]

Chief Complaint & History of Present Illness

Chief Complaint: [patient-stated reason for visit in own words]

Cataract-related symptoms: [blur / glare / halos / photophobia / reduced contrast / dim vision / monocular diplopia] — [OD / OS / OU], [which eye more symptomatic]

Symptom details: [onset], [progression], [constant / intermittent], [whether prior prescription changes improved symptoms]

Functional impact statement: [patient-described activity limitations attributable to vision changes, using patient's own words — e.g., night driving, reading, computer work, occupational tasks, hobbies] (If no functional limitations, explicitly state none reported. This is required for Medicare compliance.)

History

• Ocular history: [prior diagnoses with laterality], [prior ocular procedures with laterality], [current lens status per eye]
• Surgery-relevant systemic history: [diabetes, cardiovascular/pulmonary disease, movement disorders, cognitive impairment, severe anxiety, sleep apnea, positioning limitations]
• Medication considerations: [alpha-1 antagonist history including tamsulosin — document even if discontinued], [anticoagulant/antiplatelet use], [chronic steroid exposure]
• Allergies: [medication allergies]

Objective

Visual Acuity

Test	OD	OS
Uncorrected (UCVA)	[UCVA OD]	[UCVA OS]
Presenting (habitual)	[presenting VA OD]	[presenting VA OS]
Best-corrected (BCVA via manifest refraction)	[BCVA OD]	[BCVA OS]
Near acuity	[near OD]	[near OS]
Glare/BAT (if performed)	[method, setting, result OD]	[method, setting, result OS]

(If BCVA via manifest refraction was not obtained, document reason and plan to complete. BCVA must be established through refraction, not habitual correction, for Medicare compliance.)

Refraction: OD: [sphere/cyl x axis → BCVA]; OS: [sphere/cyl x axis → BCVA]

Pupils: [size, reactivity, RAPD present / absent] IOP: [OD / OS] [method] [time]

Anterior Segment

• Cornea/Ocular surface: [findings relevant to surgery and refraction]
• Anterior chamber: [depth, inflammation, pseudoexfoliation/phacodonesis if present]
• Lens OD: [cataract type: nuclear sclerosis / cortical / PSC / mixed], [severity grade]
• Lens OS: [cataract type: nuclear sclerosis / cortical / PSC / mixed], [severity grade]
• Correlation: [lens opacity correlates with symptoms and acuity: yes / no / uncertain — brief rationale]

Dilated Fundus Exam

Dilation: [dilated / undilated] [agents if applicable]

• Optic nerve: OD: [findings]; OS: [findings]
• Macula: OD: [findings]; OS: [findings]
• Vessels/Periphery: OD: [findings]; OS: [findings]
• Posterior segment co-morbidities affecting visual prognosis: [condition and laterality / none]
• View limited by cataract: [yes — specify degree / no]

Ancillary Testing: [OCT, topography, B-scan, or other — include indication, key results, and interpretation] (Only include tests performed. Omit this line if none.)

Assessment

Cataract — [OD / OS / OU]: [type(s)], [severity grade], [visually significant / not visually significant]

• Evidence on exam: [summary of lens findings]
• Functional impairment attributable to cataract: [specific activities affected / none]
• Correctability with glasses: [BCVA achieved / minimal improvement with refraction] (State whether functional impairment is correctable with tolerable refractive change.)
• Co-morbid ocular conditions affecting prognosis: [conditions with laterality / none]

(If symptoms or BCVA do not correlate with cataract severity, include differential diagnosis.)

Additional diagnoses: [other relevant diagnoses with laterality and brief assessment]

Plan

Cataract — [OD / OS / OU]: [monitoring / referral for surgical consultation]

If monitoring:

• [Optimized refraction provided / no change indicated]
• Counseled that cataracts typically progress and surgery is definitive treatment when function is affected
• Follow-up: [interval] for [purpose]
• Return precautions: sudden vision change, eye pain, flashes/floaters

If referral:

• Referral rationale: [statement linking functional impairment to cataract findings and BCVA/glare results]
• Shared decision-making: Discussion occurred; patient expresses [preference and readiness for surgical consultation]
• Referral to: [surgeon/clinic] — [routine / expedited (reason)]
• Pre-op considerations for surgeon: [alpha-1 antagonist history, anticoagulation, ocular surface status, zonular/PEX concerns, co-morbidities, anesthesia considerations as applicable]
• Risks, benefits, alternatives, and lens options to be discussed in detail by surgeon
• Optometry follow-up: [timing and purpose]

Additional diagnoses plan: [management for other active problems]